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FOREWORD

It gives me great satisfaction to present the Committee’s Report constituted by the


Government of the Punjab, Specialized Healthcare & Medical Education Department
vide Notification No.SO(DEV-I)15-7/2004(P-IV), dated 3rd July 2017 to formulate
recommendations for efficient use of existing burn centres and establishment of new
burn centres in Punjab.
Multiple meetings of the Committee were arranged at Jinnah Burn & Reconstructive
Surgery Centre, Lahore pursuing the following TORs set by the Government.
i. Efficient and coordinated mechanism to use the available healthcare
facilities in the existing burn centres
ii. To propose improvements in the existing setups at tertiary care
hospitals and to develop a system of collaboration between such
facilities and the Regional state of the art burn centres at Lahore,
Multan and Faisalabad.
iii. Additional requirement of trained / skilled Human Resource for the
existing burn centres.
iv. Requirement of establishment of new burn centres in accordance with
international standards in view of the population and distance from the
existing burn centres etc.
v. Requirement of training facilities for the human resource for the
Regional Burn Centres and existing setups in the tertiary care
hospitals.
The following areas were addressed to frame recommendations: -
 Assessment of available facilities (logistics, human resources etc.)
 Standards of Practice (SOPs) for referral of patients
 Induction of staff as per approved yardstick
 Establishment of new 80-Beds Burn Centres (at district level),
40-Beds Burn Units (at tertiary care hospitals) and 10-Beds Burn Facilities
(at DHQ / THQ level) essentially required to meet the challenges of burn
calamities / disasters increasing day-by-day.
 Needs-based training on short term and long term basis

The Committee has made a number of recommendations that it hopes will help to
revamp burn care services, improve our prevention activities and result in better
quality care and support of burns survivors with coordinated effort.
I would like to take this opportunity to thank my Committee colleagues for their
contribution to the report specially who travelled to JB&RSC Lahore from Multan,
Bahawalpur and Faisalabad. My special thanks to Mr. Muhammad Ali, a member of
my staff for compiling this report with dedication & commitment.

PROF. MOAZZAM NAZEER TARAR, (SITARA-E-IMTIAZ)


FRCS, FCPS
CHAIRMAN
TERMS & GLOSSARY
LMICs Low and Middle income countries
HICs High Income Countries
WHO World Health Organization
PC-1 Planning Commission Form number 1
C&W Civil and Works
ICU Intensive Care Unit
HDU High Dependency Unit
N/A Not Available
OPD Out-patient Department
USG Ultrasonography
CSSD Central Sterile Services Department
JB&RSC Jinnah Burn & Reconstructive Surgery Centre
DVT Deep Venous Thrombosis
ECG Electrocardiogram
LED Light Emitting Diode
SS Stainless Steel
I.V Intra-venous
OT Operation Theatre
CVP Central Venous Pressure
BP Blood Pressure
ABGs Arterial Blood Gases
CO2 Carbon dioxide
LMA’s Laryngeal Mask Airway
A-line Arterial Line
KPO Knowledge Process Outsourcing
AMS Additional Medical Superintendent
DMS Deputy Medical Superintendent
CCTV Closed Circuit Television
HVAC Heating, Ventilation and Air Conditioning
IT Information Technology
AMI Autonomous Medical Institution
AIMC/JHL Allama Iqbal Medical College/Jinnah Hospital Lahore
DDO Drawing and Disbursing Officer
PIBC Pak Italian Burn Centre
NHM Nishtar Hospital Multan
SHC & ME Specialized Health Care & Medical Education
SNE Schedule of New Expenditure
DHQ District Headquarter
THQ Tehsil Headquarter
NTS National Testing Service
TBSA Total Body Surface Area
COHb Carboxy Hemoglobin
MDT Multi-Disciplinary Team
SOPs Standard Operating Procedures
ATLS Advanced Trauma Life Support

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SECTION – 1:

INTRODUCTION
Burn injuries are a global public health problem with physical, psychological,
and economic implications for patients, their families, and society as a whole
Around 90% of all burns injuries occur in low- and middle income countries
(LMICs). Burns are the fourth leading cause of injury following road traffic
injuries, falls, and interpersonal violence, accounting for 5 - 12% of all injuries
worldwide and around 11 million patients requiring medical attention About
265,000 people die each year due to burn injuries according to the World
Health Organization (WHO). This current burden of burn injuries is deeply
inequitable, with incidence disproportionately affecting the poor and the
vulnerable.
Around two-thirds of burn injuries occur in the African, Eastern Mediterranean
and South-East Asia regions of the WHO. The annual incidence of burn
injuries in the LMIC’s is estimated to be 243 per 100,000 population,. Mortality
rates from fire-related burns are the highest in these regions (11.6 per
100,000 population) and when compared to the 1 death per 100,000
population found in high-income countries (HICs), this is one of the largest
discrepancies for any injury mechanism. The pattern of burn injury and the
groups affected in LMICs and HICs also differs; for example, among the 15-59
year age group, the mortality rate due to fire-related burn injury in HICs is
twice as high for males compared to females, while the reverse is true in
LMICs.
Burn injury is an important yet under-researched area in Pakistan. The Global
Burden of Disease 2010 study estimates that the age-standardized mortality
rate for injury caused by fire, heat, and hot substances is 5.8 per 100,000
population in Pakistan. A burn facility-based study from Karachi estimated
burn-associated mortality rate among adults between 15 - 55 years to be even
higher at 10.2 per 100,000 population. Existing data make it difficult to
estimate the true burden of burn injuries on the general population and little is
known about the epidemiology of burn injury in the population that does not
present to specialized burn centers. This is an important knowledge gap as
specialized burn centers are not accessible to a large portion of the Punjab.
Establishment of National and Provincial burn registries are absolutely
essential to collect reliable data in order to scientifically determine the need
for therapeutic and preventive services for burn injuries.
There are only three burn centres for a population of 112 million in Punjab.
The incidence of burn injuries specially those requiring specialized treatment
is one of the highest amongst low and middle income countries (LMIC). All
three facilities are either recently established or still undergoing
commissioning.in the absence of any substantial history of modern burn care
in Pakistan. Required human resource for such facilities is also scarcely
available. There is a need for development of standard operating procedures,
protocols, best clinical practice guidelines and quality assurance in service
delivery for complex burn injuries management.

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Current state of affairs about burn care in Punjab can be summarized in
general term as under: -

1. Burden of burn patients against available facilities;


There are only three specialized burn centres in major cities of Punjab
namely Lahore, Faisalabad and Multan. The patients that these centers
cater come from all over Pakistan and even neighbouring Afghanistan.
So a large number of patients attend these centres overwhelming the
available facilities. This disproportionately heavy work load precludes
possibilities of improving burn care in these newly established burn
centres.

2. Burn care services at distant hospitals; no effective burn services are


available in primary, secondary and even many tertiary care hospitals at
the periphery. This contributes to inappropriate referral to existing
centres and compounds the work load issue.

3. Poor communications and transportation infrastructure; although


situation has improved in Punjab with the construction of farm to market
roads and 1122 ambulance service and recent initiative by the Punjab
government of streamlining hospital to hospital transportation of patients
through rescue 1122 ambulance service. But there are major gaps in
communication and coordination between the referring and treating
health care professionals, resulting in inappropriate referrals and lapses
in early resuscitation of the burn victims.

4. Lack of emphasis on burn care training at different levels of


medical education; both in undergraduate curriculum and post graduate
surgical training burn care remains a neglected subject. This breeds lack
of understanding and insight into burn injury resulting in poor standard of
first aid, triage, emergency room management and referral.

5. Shortage of trained human resource, There is limited understanding


of the concept of dedicated burns professionals (both medical and
nursing) with appropriate specialist skills. There is also shortage of
anesthetists, intensivists, nurses and allied health professional in all burn
centres. The burn care is taken as untidy, labor intensive, one of the
toughest task to accomplish among the doctors and paramedical staff
with obvious negative consequences for the recruitment, motivation and
retention of staff. In the absence of any financial incentives even trained
staff tends to look for alternative avenues.

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6. The absence of clinical standards, protocols, and guidelines for burn
care at all levels of care. Lack of effective monitoring and quality
control programs in burn care services.

7. The late presentation of the patient, due to lack of burn care facilities
locally, patients present late with more complications, resulting in
increased morbidity and mortality.

8. lack of relevant research and training on best practices in burn care.


There is also no central burn registry for Punjab / Pakistan.

9. Lack of legislation for prevention of burn injuries and its


implementation strategy. Safety legislation is not very effective in our
country and its implementation is even poorer.

This report will elaborate on these issues and analyze the available
facilities and will recommend measures to improve management of burn injury
patients in Punjab.

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SECTION - 2:

REVIEW OF SERVICES AT EXISTING BURN CENTRES

2.1: Overview
During the first meeting of this committee on 8-7-2017, it was decided to
gather information on a proforma about the available facilities in term of
logistics, human resource and equipment etc. The aim was to assess any
shortcomings and to determine minimum service delivery standards for these
burn centers. Each burn center management was asked to provide detail of
available facilities as a checklist regarding bed capacity, specialized treatment
areas, equipment, and human resource. They were also asked to provide a
brief outline of their management structures.

2.2: Infrastructure
All three burn centres were designed and built after going through formalities
of PC-I and there subsequent revisions. Jinnah Burn and Reconstructive
Surgery Centre at Lahore was designed by a consultant M/S Progressive
Consultants Lahore with input from end-users. The centres at Multan and
Faisalabad had their building plans proposed by the architect of C&W
Department.
S.# Departments / Sections Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre Required
Reconstructive Centre, Nishtar Allied Hospital, for All
Surgery Hospital, Faisalabad
Acute and Core Clinical Centre, Lahore Multan
Facility Available N/A. Available N/A. Available N/A.
1. Dedicated Reception and Yes yes
Resuscitation area with
1. Burn shower area Yes yes Yes
2.Emergency operation Yes yes Yes
theatre
4. Burn ICU 10 Beds 10 NIL
Beds
5. Burn HDU 6 Beds 5 Yes
1.With adjacent Burn Beds
Shower area
6. Acute Burn operation 2 Nos. 2 02
theatres
7. Burn reconstruction ward 24 Beds Yes Yes

Male 11 18
Beds
Female 10 18
Beds

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S.# Departments / Sections Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre Required
Reconstructive Centre, Nishtar Allied Hospital, for All
Surgery Hospital, Faisalabad
Centre, Lahore Multan
Available N/A. Available N/A. Available N/A.
10. Beds for Reconstructive 24 Beds
surgery ward 12 18
(Post tumor excision defects, Beds
Congenital deformities, Post
traumatic defects )
11. Isolation Rooms 6 Beds 5 09
Beds
12. Burn reconstruction 4 Nos. 2 05
operation theatres including Modular
modular theatres OT
13. Day care surgery area No Nil

14. OPD Yes yes Yes


With dressing rooms Yes yes 02
16. Any other facility (please Laser
specify) pulse
diode
Supportive Services
17. Diagnostics
Radiology: 01 Digital Only
X-ray General Mobile portable
02 X-Ray machine
Portable
s
USG Yes Yes No
LASER Doppler Yes Yes No
21. Laboratory / blood bank Yes Yes No
without
culture
machine
22. CSSD Yes Yes No

23. Laundry Yes No No

24. Kitchen Yes No No

25. Rehabilitation / Yes Yes


physiotherapy services
26. Psychiatry services Yes No No

27. Speech therapy services Yes No No

28. Nutritional services Yes No No

29. Occupational services Yes Nil No

30. Research / training facility: Yes No stem cell lab No


Stem cell lab Only skin bank
Skin bank with180 refrigerator
Any other (please
specify)
31. Library Yes Yes No

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32. Auditorium/lecture theatre Yes Confe- No
260 seats rence
Auditorium room for
26 seats 30 Person
Conf.
Room
33. Any other facility (Please
specify)
2.3: Equipment
According to the Performa a list of equipment necessary for modern burn
centers was developed. The information regarding availability of equipment
in JB&RSC, Lahore, Pak Italian Burn Centre, Nishtar Hospital, Multan and
Burn Centre Allied Hospital, Faisalabad is presented in tabulated form.

Equipment
S.# Departments / Sections Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre Required
Reconstructive Centre, Nishtar Allied Hospital, for All
Surgery Hospital, Faisalabad
Equipment Centre, Lahore Multan
Available N/A. Available N/A. Available N/A.
1. Ventilators including portable 6 14 No
ventilators

2. Fiber-optic bronchoscopes 2 Nil No

3. Compression devices for DVT 1 Nil No


prophylaxis
4. Portable x-ray machine 2 Yes Yes

5. Bedside USG 1 Yes No

6. Hydro-therapy bath tubs 1 2 03

7. Burn shower trolleys 5 4 05

8. Burn lifter trolleys 4 3 no

9. Air fluidized bed with beads -- Nil no

10. Geysers with mixing taps 12 02

11. Beds with weighing scales -- no

12. Environment infection control -- Nil no


system
13. Electric Dermatomes 7 1 No

14. Pneumatic Dermatomes 6 3 01

15. Battery operated Dermatomes 3 Nil No

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16. Skin graft mesher 6 3 03

17. Skin graft mesher with MEEK -- Nil No


technology
18. Watson knives 20 Nil 06

19. Infiltration pumps -- 15 10

20. Micro-scope for free tissue -- 1 No


transfer
21. Fat transfer system -- Nil No

22. Laser machines (please -- 01 no


specify) pulse
diode
23. Anesthesia Machines 9 5 07

24. Cardiac Monitors 24 5 10

25. Invasive cardiac Monitors -- 15 No

26. Pulse Oximeters 20 3 12

27. ECG Machine 6 1 03

28. Defibrillator 4 4 02

S.# Departments / Sections Name of Institute


Jinnah Burn & Pak Italian Burn Burn Centre Required
Reconstructive Centre, Nishtar Allied Hospital, for All
Surgery Hospital, Faisalabad
Equipment Centre, Lahore Multan
Available N/A. Available N/A. Available N/A.
29. Operation Table 9 5 07

30. LED light 9 5 05

31. Doppler with trolley 3 1 No

32. Nerve Stimulator 1 nil Nil No

33. Portable OT Light 10 nil Nil 12

34. Low air loss mattress 8 nil Nil 12

35. Electric K-wire driver 2 01 02

36. Electric drill 2 02 No

37. Pneumatic drill 1 0 Nil 01

38. Hand drill 6 1 02

39. Electric saw -- 1 01

40. Pneumatic Tourniquets 6 4 06

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41. SS Bowls -- 6 18

42. Bowl stand -- Nil 06

43. SS dressing Drum small -- 20 12

44. SS dressing Drum Large 20 30 12

45. Instrument Trolley 50 12 18

46. Emergency Trolley -- 4 06

47. Drum stand 16 Nil 06

48. Basin stand 12 Nil 02

49. I.V stand 70 15 72

50. Patient screen 25 5 30

51. Oxygen cylinder trolley 7 3 12

52. Surgeon operating chair 40 Nil No

53. Patient SS stools 50 20 30

54. Foot steps 45 15 30

55. Spirit Jar -- Nil 12

56. Fiber-optic Laryngoscope -- Nil 01


Paeds
57. Fiber-optic Laryngoscope Adult Nil 02

58. Ambu bag adult 30 4 09

59. Wheel chairs 20 5 15

60. Liposuction unit 1 1 02

61. Hot air oven 1 3 02

62. Hot air cabinet 4 1 01

63. Medicine refrigerator 1 nil Nil 03

64. Headlight with LED source 3 1 04

65. Blood warmer -- 4 03

66. Body warmer blankets 2 nil Nil No

67. CVP set -- Nil 06

68. Spinal set -- Nil 12

69. Glucometers 14 5 04

70. Scrub unit 3 2 03

10
71. Electro-Hydraulic shifting 4 10 No
trolleys
72. Shoe racks wooden 10 5 No

73. Shoe racks steel 3 0 Nil No

S.# Departments / Sections Name of Institute


Jinnah Burn & Pak Italian Burn Burn Centre Required
Reconstructive Centre, Nishtar Allied Hospital, for All
Surgery Hospital, Faisalabad
Equipment Centre, Lahore Multan
Available N/A. Available N/A. Available N/A.
74. CSSD trolleys 4 3 02

75. Crash trolleys 4 4 No

76. Linen trolleys 2 2 04

77. BP apparatus 64 50 30

78. Stethoscopes 50 20 30

79. Iron cupboards 21 5 No

80. Staff lockers 4 300 No

81. Laundry baskets 2 0 Nil No

82. Small baskets 0 Nil 15

83. Dust bins 105 50 60

84. Water dispensers 17 10 02

85. Electric heaters 28 0 Nil 08

86. Suction machines 24 5 12

87. Nebulizers 2 4 08

88. Mayo trolleys 16 10 18

89. X-ray illuminators 33 4 10

90. Venturi 50 50 No

91. Diathermy machines 9 6 06

92. Plastic surgery & burn 18 5 04


instrument sets
93. Hand surgery instrument sets 6 1 02

94. Cleft palate sets 4 5 01

95. Rhinoplasty sets 3 2 01

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96. General surgery instrument 6 5 02
sets
97. Micro surgery instrument sets 5 1 no

98. Micro clamp trays 1 No

99. Tracheostomy sets 2 2 03

100. Cidex tray 4 2 06


101. Chital jar 0 Nil 02
102. Sewing Machine 1 0 Nil No
103. Binocular Loupes with LED 0 Nil No
lights
104. A-line sets 0 Nil No
105. Pulse dye laser 1 1 No
106. Laser chair 2 1 No
107. Cooling system 1 0 Nil No
108. Examination couch 31 10 12
109. Desktop 0 Nil No
110. Electro-hydraulic beds 21 15 12
111. Blood Gas analyzer (ABG’s 1 1 01
machine)
112. Infusion pumps 15 12
113. Patient control analgesia 0 Nil -- No

S.# Departments / Sections Name of Institute


Jinnah Burn & Pak Italian Burn Burn Centre Required
Reconstructive Centre, Nishtar Allied Hospital, for All
Surgery Hospital, Faisalabad
Equipment Centre, Lahore Multan
Available N/A. Available N/A. Available N/A.
114. Syringe pumps 0 Nil -- No
115. End tidal CO2 probes 0 Nil -- No
116. Emergency resuscitation carts 4 -- No
117. Hygienic chair for toilet 2 -- Nil -- No
118. Pressure infuser 2 -- Nil -- No
119. Long venous catheters -- Nil -- No
120. LMA’s 9 10 -- No
121. Pressure monitoring -- Nil -- No
transducers
122. Mechanism for purchase of -- Nil - No
disposables including
specialized burn dressings &
skin substitutes

2.4: Human Resource:


The most precious asset for any organization is its skilled and
loyal human resource. Working in a burn care facility can be quite taxing both
physically and emotionally. Keeping the staff morale high can be quite

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challenging. Incidence of on job stress and resulting anxiety and depression is
one of the highest amongst burn care health workers. Burn care facilities
globally have high staff turnover. Special incentives are offered in developed
high income countries that can be quite attractive for well-trained individuals
from low income countries like ours.
A yardstick was developed by the department of specialized healthcare and
medical education yardstick. (Annexed-I). The information provided by the
burn centres regarding availability / non availability of human resources is
presented in tabulated form: -
S.# Name of Post BPS Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
1. Professor of Plastic and Burn 20 1 1 1 0 01 01
Reconstructive Surgery
2. Associate professor of Plastic 19 2 1 2 1 01 01
and burn reconstructive surgery
3. Assistant professor of plastic and 18 4 4 03 3 02 00
burn reconstructive surgery

S.# Name of Post BPS Name of Institute


Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
4. Senior registrar of plastic and 18 8 8 4 2 06 00
burn reconstructive surgery
including those dedicated to
acute burn care
For Burn ICU
For Burn HDU 0
For Burn Reconstruction ward 0
For Reconstructive surgery ward 0
8. Professor of anesthesia 20 1 0 1 0 00 00

9. Associate professor of anesthesia 19 1 1 1 0 01 00

10. Assistant professor of anesthesia 18 2 1 2 1 00 00

11. Senior registrar of anesthesia 18 2 2 06 0 04 00


including those dedicated to
acute burn care For Burn ICU
For Burn HDU 0
For Burn Reconstruction ward 0
For Reconstructive surgery ward 0
15. Consultant Anesthetist 18 2 0

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16. Medical officer of plastic and burn 17 32 20 22 3 24 06
reconstructive surgery including
those dedicated to acute burn
care including those dedicated to
acute burn care
For Burn ICU
For Burn HDU
For Burn Reconstruction ward
For Reconstructive surgery
ward
20. Medical officer of anesthesia 17 14 14 15 3 04 02
including those dedicated to
acute burn care
For Burn ICU
For Burn HDU
For Burn Reconstruction ward
For Reconstructive surgery
ward
23. Post graduate residents Plastic 10 4 06 04
and reconstructive surgery
24. Head nurses including those 17 8 8 6 6 06 04
dedicated to acute burn care
For Burn ICU
For Burn HDU 2 0
For Burn Reconstruction 2 0
ward
For Reconstructive 2 0
surgery ward
For Acute burn operation 2 0
theatres
For Burn Reconstruction 0
operation theatres
For day case surgery unit 0
For OPD 0
S.# Name of Post BPS Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
32. Staff nurses including those 16 90 85 66 (female) 22 90 35
dedicated to acute burn care
For Burn ICU Male
Female
For Burn HDU
Male
Female
For Burn Reconstruction
ward Male
Female
For Reconstructive
surgery ward
Male
Female
For Acute burn operation
theatres
Circulating nurses
Scrub nurses

14
For Burn Reconstruction 16 08 0
operation theatres
Circulating nurses
Scrub nurses 12 4
For day case surgery
operation theatres
Circulating nurses
Scrub nurses
For OPD
47. Dresser 5 15 15

48. Ward servants including those 1 15 15 5 0 08 06


dedicated to acute burn care
For Burn ICU
For Burn HDU
For Burn Reconstruction ward
For Reconstructive surgery
ward
For day case surgery unit
For OPD
53. Aya’s including those dedicated 1 10 10 3 3 04 02
to acute burn care
For Burn ICU
For Burn HDU 10 0
For Burn Reconstruction ward
For Reconstructive surgery
ward
For day case surgery unit
For OPD
59. Ward Bearer 1 8 8

S.# Name of Post BPS Name of Institute


Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
60. Security guards including those 5 13 13 14 14 18 08
dedicated to acute burn care 1 8 8 12 6
For Burn ICU
For Burn HDU
For Burn Reconstruction ward
For Reconstructive surgery
ward
For Acute burn operation
theatres
For burn reconstruction
operation theatres
For OPD
67. Burn washing attendants 1 0 0
including those dedicated to
acute burn care

15
For Burn ICU
Male
Female
For Burn HDU
Male
Female
70. Sanitary workers/ sweepers 1 30 30 38 24 24 18
including those dedicated to
acute burn care
For Burn ICU
For Burn HDU
For Burn Reconstruction ward
For Reconstructive surgery ward
For Acute burn operation theatres
For burn reconstruction
operation theatres
For Radiology department
For OPD
77. Stretcher Bearer / Porter 1 4 4 10 0 04 04
including those dedicated to
acute burn care
For Burn ICU
For Burn HDU
For Burn Reconstruction ward
For Reconstructive surgery ward
For Acute burn operation theatres
For burn reconstruction
operation theatres
For OPD
84. Operation theatre technologist 17 1 0 16 10

For Acute burn operation


theatres
For burn reconstruction
operation theatres

S.# Name of Post BPS Name of Institute


Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
86. Operation theatre technician / 9 16 16 9 0
Assistant 9 5 5
6 3 2
For Acute burn operation
theatres
For burn reconstruction
operation theatres
For day case surgery unit
92. Anesthesia technician/Assistant 17 2 0 05 05
9 10 10 8 0
3 4 4
For Acute burn operation
theatres
For burn reconstruction

16
operation theatres
97. Operation Theatre Attendants 3 14 14 9 6 08 05

For Acute burn operation


theatres
For burn reconstruction
operation theatres
For day case surgery unit
100. Anesthesia attendant 3 6 6
For Acute burn operation
theatres
For burn reconstruction
operation theatres
103. Sterilizing operator 6 6 1 2 0 02 00
9 2 0
For Acute burn operation theatres
For Burn Reconstruction
Operation Theatres
107. Radiologist 18 1 0 01 0 01 00
108. Medical officer Radiology 17 3 2 01 0 01 01
109. X-ray technician 9 2 2 1 1 03 01
110. Radiographer 9 2 2
111. X-ray/ USG attendants 2 5 2 3 0
Male
Female
113. Receptionists 6 -- -- 05 1 02 02
For OPD 5 2 2
For Radiology
For ICU/HDU
For inpatient department
For Radiology
118. Computer Operator (KPO) 12 8 8 04 1 02 01
For OPD
For Operation theatres
For ICU/HDU
For Burn Reconstruction ward

S.# Name of Post BPS Name of Institute


Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
121. Store/ Record keeper 6 3 1
For Burn ICU
For Burn HDU
For Burn Reconstruction ward
For Reconstructive surgery
ward
For Acute burn operation
theatres
For burn reconstruction
operation theatres
For OPD
127. Photographer 8 2 1 1 0
For OPD

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For Inpatient Department
Rehabilitation Center
128. Senior Physiotherapist 18 1 0 1 0
129. Physiotherapist 17 3 3 2 0 2 2
16 1 1
131. Clinical Psychologist 17 1 1 1 0 1 1
132. Speech therapist 16 1 0 1 0 1 0
133. Occupational therapist 16 1 0 1 0 0
134. Speech therapy technician 9 1 0 0
135. Dental technician 9 1 0 1 0 0
136. Occupational therapy assistant 6 2 0 1 0 0
137. Physiotherapy Aid Assistant 9 2 2
Administration Department
138. Executive Director / Professor of 20 1 0 0
Plastic Surgery
139. Additional Director (AMS) 19 1 0 2 1 1 0
140. Assistant Director (DMS) 18 2 0 4 0 1 0
141. Admin officer 1 0 0 0 0
142. Social welfare officer 17 1 0 1 0 0 0
143. Social Medical officer 17 1 0 1 0 0
144. Research & Development officer 17 1 0 1 1 0
145. Office superintendent 17 2 2 1 0 1 1
146. Personal assistant 16 1 0 1 0 0
147. Stenographer 14 2 1 2 0 0
148. Assistant 16 1 0 1 0 0
149. Senior clerk 14 3 2 3 1 2 0
150. Junior clerk 11 1 1 4 0 4 1
151. Telephone supervisor 11 1 0 1 0 0 0
152. Telephone operator 07 6 6 6 4 3 1
153. Daftri 2 1 0 1 0 0
154. Naib Qasid 1 13 6 6 4 6 4
155. Sanitary worker/sweeper 1 24 24 6 2
Finance Department
156. Director Finance 0 0 0
157. Budget & Accounts officer 17 1 0 1 1 0
158. Audit officer 17 1 0 0
159. Accounts Officer 16 1 0 0
160. Assistant Accounts officer 16 1 1 1 0 0
S.# Name of Post BPS Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
161. Accounts assistant 11 2 1 1 0 1 01
162. Cashier 1 0 0 0 0
163. Almoner 9 2 2 1 0 0
164. Junior clerks 1 0 0
165. Computer operators 1 0 0
166. Naib Qasid/ Peon 2 0 0
Purchase Section
167. Purchase officer 19 1 0 0 0 0
168. Purchase/Junior clerk 0 0 0
169. Computer operator 0 0 0
170. Naib Qasid/ peon 0 0 0
Legal section

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171. Law officer 0 0 0
172. Computer operator 0 0 0
173. Naib Qasid/peon 0 0 0
Human Resource Department
174. Director HR 18 1 0 0 0 0
175. Assistant Director HR 0 0 0
176. Junior clerk 0 0 0
177. Naib Qasid 0 0 0
Miscellaneous
178. Sanitary inspector 1 0
179. Security supervisor 0 0
180. CCTV operators 0 0
181. Drivers 4 2 1 0 0 0
182. Ambulance Services 5 for 5 5 0
(drivers/number of available ambulances
ambulances)
183. Head Mali 1 0 0 0 0
184. Mali / Gardner 1 1 1 1 1 0
185. Clinical Nutritionists / Dietitian 16 1 0 1 0 0
186. Dietitian 9 1 0 2 0
187. Cook 1 0 0 0
188. Chapatiman 1 0 0 0
189. Service Bearers 1 24 24 0
CSSD
190. CSSD officer 18 1 0 0 0 0
191. Supervisor 14 1 0 0 0 0
192. Assistants 11 3 0 0 0 0
193. Washer & Scrubber 1 2 2 0 0 0
194. Packers 1 2 2 0 0 0
195. Sterilizing Operators 9 6 1 2 0 0
196. Porters 1 0 0
197. CSSD attendant 1 4 3 2 0 0
198. Security guard 5 0 0 0
Planning & Development / Works Department
199. Executive engineer (XEN) 0 0 0
200. Sub Engineer (Civil / Electrical) 14 2 2
201. Supervisor 0 0 0
S.# Name of Post BPS Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
202. Plumber 5 5 4 2 1 1 1
203. Electrician 5 4 4 2 1 2 2
204. Generator operator 0 0 0
205. HVAC mechanic 5 4 4 1 0 2 0
206. Lift operator 1 6 6 6 4 3 3
207. Carpenter 3 1 1 1 0 0
208. Carpenter helper 1 1 0 0
209. Masson 5 1 0 1 0 0
210. Masson helper 1 1 0 0 0
211. Sewerman 1 1 1 1 1 0
212. Painter (masonry + wood &metal) 1 1 1 0 0 0
213. Painter helper 1 1 1 0 0 0
214. Naib qasid/ Dak runner 0 0

19
215. Boiler operator 5 1 1 0 0 0
216. Skilled helper 0 0 0
217. Tube well operator 0 0 0
General Workshop
218. Biomedical Engineer 17 1 0 1 1 01 0
219. Electro-medical Technician 12 2 1
220. Biomedical Technician 9 2 0 0
221. Biomedical Assistant 0 0 0
222. Welder 0 0 0
IT / Computer Section
223. Director IT Department 0 0 0
224. Server Room Incharge 0 0 0
Software/HMIS System/ EMR
225. Software Engineers 0 0
226. Web Master/ Assistant Software 0 0 0
engineer
227. Computer Operator 0 0 0
Hardware Section
228. Hardware Engineer 0 0 0
229. Assistant Hardware engineer 0 0 0
Blood Transfusion Department
230. Blood Transfusion Officer 17 2 0 0 0
231. Staff Nurse 0 0
232. Phlebotomist 0 0
233. Laboratory technician 9 1 1
234. Laboratory assistant 0 0
235. Lab Attendants 0 0
236. Sweepers 0 0
237. Security guards 0 0
Pathology Department
238. Pathologist 18 1 1 1 0 1 0
239. Biochemist/Chemical Pathologist 0 0 0 0
240. Medical Technologist 0 0 0 0
241. Laboratory Technician 0 0 0 0
242. Computer Operator 0 0 0 0
243. Clerk / Receptionist 0 0 0 0
244. Laboratory assistant 0 0 0 0
S.# Name of Post BPS Name of Institute
Jinnah Burn & Pak Italian Burn Burn Centre
Reconstructive Centre, Nishtar Allied Hospital,
Surgery Centre, Hospital, Multan Faisalabad
Lahore
Sanctioned Filled Sanctioned Filled Sanctioned Filled
245. Lab attendants 2 2 2 0 0 0 0
246. Sanitary worker/ sweepers 0 0 0 0
247. Security Guard 0 0 0 0
Laundry Department
248. Laundry Manager 0 0 0 0
249. Laundry Operator/ Dhoby 0 0 0 0
250. Helper 0 0 0 0
251. Laundry Attendant 1 2 1
Store Department
252. Store officer 0 0 0 0

253. Store supervisor 0 0 0 0

20
254. Store keeper 1 1 0 0

255. Computer operator 0 0 0 0

256. Helper 0 0 0 0

Pharmacy Department
257. Deputy drug controller 0 0 0 0
258. Pharmacist 1 0 1 1
259. Dispenser 3 0
260. Pharmacy attendant 0 0
Library /Auditorium Department
261. Librarian 0 0
262. Assistant librarian 0 0 1 1
263. Projector operator 0 0 0 0
Stem Cell / Skin Bank
264. Naib Qasid 0 0 0 0
265. Professor 0 0 0 0
266. Associate professor 0 0 0 0
267. Assistant professor 0 0 0 0
268. Skin bag coordinator 0 0 0 0
269. Skin bag technologist /OT 0 0 0 0
technologist
(with B. Sc Hons. Qualification)
270. Research officer 0 0 0 0
271. Assistant research officer 0 0 0 0
272. Skin bank assistant /operation 0 0 0 0
theatre assistant
273. Laboratory assistant 0 0 0 0
274. Attendant 0 0 0 0
275. Sanitary worker /sweeper 0 0 0 0
276. Security guard 0 0 0 0
Micro Surgery Training Lab
277. Micro Surgery technologist /OT 0 0 0 0
technologist
(with B.Sc Hons. Qualification)
278. Operation Theatre technician / 0 0 0 0
assistant
279. Attendant 0 0 0 0
JINNAH BURN & RECONSTRUCTIVE SURGERY CENTRE, LAHORE
 Total Sanctioned Posts: 541
 Filled: 424
2.5: Management

Jinnah Burn and Reconstructive Surgery Center (JB&RSC) has a


proposed management structure in the PC-I envisaging it as Autonomous
Medical Institution (AMI) with its own Board of Management, academic
autonomy as Institute of Burn Care and Reconstructive Surgery and clinical
linkages with Allama Iqbal Medical College & Jinnah Hospital Lahore. A
formal request to implement that is under consideration by SHC&MED. The
existing situation of its management structure is: -

21
The center is working as part of AIMC /JHL Complex. The Executive Director
who is also Professor of Plastic Surgery has recently been declared as
Drawing and Disbursing Officer (DDO) with financial and administrative
powers of a Medical Superintendent of attached teaching hospital. A separate
Cost Center has been allocated for its recurring expenses. JB&RSC has its
own management infrastructure in place that can be easily upgraded with
requisite addition to an AMI status.

Proposed management structure of Jinnah Burn & Reconstructive Surgery


Centre, Lahore (Autonomous Medical Institute)

22
Pak Italian Modern Burn Center is affiliated with Nishtar Hospital Multan
(NHM)and is not a separate financial and administrative entity. It is dependent
on NHM for all kind of supplies, human resources and utilities. Recently the
specialized healthcare and medical education department (SHC&MED),
Punjab has proposed it to be an independently managed allied hospital
attached to Nishtar medical university.

Allied Burn Center Faisalabad has an organizational structure similar to


PIBC Multan. Similar development is expected for this institution as regards
its management.

23
2.6: Recommendations to improve services at the existing burn
centers
2.6(a) Referring to section 2.2 the shortcomings in infrastructure
was highlighted under sub heading Infrastructure. The committee
proposes that respective head of burn centers be asked to furnish a
proposal to rectify these issues in shortest possible time with minimum
expenditure in such a way that proposed civil work would not interfere
with functioning of the unit.

2.6(b) Referring to section 2.3 the shortfalls in inventories of the


equipment was reviewed by the committee. The respective heads
were asked to initiate a demand of requisite equipment. The lists
provided by all three centers are discussed under sub section 2.3
above. The committee recommends that the SH&MED should take
prompt necessary action
2.6(c) Referring to Section 2.4: The additionally required
human resource was assessed by the committee after acquiring
information from each burn centre. The committee recommends that
the respective heads of units may initiate SNE for additional
requirement of trained human resource immediately. It is also
recommended that the SHC&MED should facilitate approval of these
requirements on priority basis.
Special efforts have to be made to retain our trained staff and committee
suggests following measures to that effect;
1. Improving the working environment: In house stress
management sessions will be arranged to combat that. Other
initiatives to tide them over include; workplace social events,
high standard cafeteria and recreational facilities.

2. Incentives: financial and other ‘in kind’ incentives would go a


long way in keeping the staff morale high. special burn care
allowance should be added to the staff salaries. (equivalent to
one basic pay or market based salaries), subsidized on site
accommodation for essential on call staff will be an attractive
bonus to retain the staff.

Referring to section 2.5, the committee unanimously recommends that all the
burn centres should be independent in terms of their administrative and
financial management but remain with the medical college / university as
affiliated hospitals.

24
SECTION - 3:
REVIEW OF REFERRAL PRACTICES AND WORKLOAD AT
EXISTING BURN CENTRES

3.1 Prevalent Referral Practices


 Currently referral of burn patients to specialized burn care
cantres do not follow a standard pattern. Patients presenting to
various health care facilities are referred to these centres
without prior consultation with the doctors at these centres.
Moreover, patients who do not require specialized burn care and
the ones who can be managed at a general surgical facility or a
burn unit attached to plastic surgery department are referred to
these burn centres. This results in wastage of resources and
undue burden on these centres.

3.2 Workload
 There are only three specialized Burn centers for a population of
112 million in Punjab. Due to lack of preventive strategies, incidence of
Burn is on the rise. Currently primary, secondary and most of the
tertiary health care facilities are not providing care to acute burn
patients and most of these patients are being referred to the few
available burn units and centres. Moreover, patients who do not
present to specialized burn care facility get complicated and present
late to get treatment for these complications. This results in excessive
workload on existing centres.

3.3 Recommendations
1. The committee proposes a uniform referral guidance for these centers.
The competent authority should ensure compliance by the referring
healthcare institutions in order to prevent these centers deteriorating
into kind of dumping grounds for all kind of burn related injuries that will
render them incapable of performing their basic function of treating
complex acute burn patients in isolation with strict infection control
providing modern critical care. The referral guidelines established by
the committee are discussed at pages 26 to 37.

2. Combined specialized burn care services network should be


established comprising of regional burn centers, all tertiary care health
facilities treating adult burns population.

25
3.3 (a) Referral Guidelines
This guidance gives an idea of different level of burn services to
be established in the Punjab Burn Services Network (PBSN) and the
coordination needed to categorize burn patients for referral to these
services.
The burn care facilities can be categorized into three systems: -
a. Burn Center
This level of in-patient burn facility is for the highest level of
injury complexity. It will have a discrete land and dedicated staff.
It should have a fully equipped ICU, HDU, blood bank, 24 hour
operation theatre access within the center and should be close
to an emergency department of a tertiary care hospital. It should
have a skin bank or in close liaison with a central skin bank

b. Burn Unit
This level of in-patient facility is for the moderate level of injury
complexity and offers a separately staffed, plastic and
reconstructive surgery department at tertiary care hospital. It
should include 20 bedded burn unit with at least 4 beds as High
Dependency Unit (HDU). It is recommended that all the tertiary
care teaching hospitals should have such departments.

c. Burn Facility
This level of in-patient burn care system equates to a standard
surgical ward for the care of non-complex burn injuries. All
District Headquarter Hospitals should have 08-beds and Tehsil
Headquarter Hospital should have 04 beds allocated for this
purpose. The Burn Facility should be located adjacent to
Emergency Department or within the Surgical Unit of these
hospital.

This guidance aims to ensure that patients are referred to a burn care
service which has the relevant level of expertise and specialized
resources to optimize their treatment and recovery.

3. The pivotal role may be assigned to JB&RSC Lahore to carry out


following functions: -
(i) It will provide technical and logistic support to other burn
centers to ensure a uniform standard of care for Burn
victims.
(ii) It will also act as an advisory center for different clinical and
management issues.

26
(iii) It will be the main platform for training of human resources
coordinating with national and international sources to
provide assistance in this regard.
(iv) The Centre will run a provincial burn registry
(v) It will house central skin bank and resource center for
innovative solutions in burn care.
(vi) It will work as a nerve center during a mass burn causality
incident.

Other regional burn centers will act as territorial


headquarters to coordinate the burn care services of their region.it
includes referral service, regional bed bureau and will provide basic
level of training to non-core medical personnel acting as 1 st
responders at primary and secondary healthcare facilities.

PROPOSED MODEL OF SPECIALIZED BURN CARE NETWORK

Burn
Centre

Burn Unit

F
Burn Facility

(DHQ, THQ) Injury Complexity

GUIDANCE FOR ADMISSION OF BURN PATIENTS


Followings are the guidelines for the admission of patients affected by burn
injuries presenting into a health care facility center (THQ, DHQ OR TERTIARY
CARE HOSPITAL).

CENTRALIZED BURN BED BUREAU AND REFERRAL SERVICES: All the


burn care systems should have a well-connected burn victim registration and
referral system. A centralized burn referral service may be established along
with centralized communication through short code NTS services.it should
keep the record of all the available beds in the specific burn services by
getting updates from all centers daily. There should also be a central burn
registry. This referral service should have close coordination with 1122
services in all districts and it should also organize transfer of burn patients

27
from a lower to a higher level of burn service depending upon the severity of
the burns.

BURN MANAGEMENT AND REFERRAL CRITERIA

THE GUIDANCE FOR REFERRAL TO A BURN CENTER;


Once the patient has been admitted into a hospital, then following are factors
to consider for referral of patient to a burn center;
• TBSA: Total Body Surface Area
• Depth: The depth of burn injury
• Site: Anatomical site of the burn injury
• Mechanism: The etiology of the burn injury
• Other Factors: associated injuries/illness/condition. Parameters that
may impact on the severity/complexity of burn injury
Thresholds for the above criteria are listed as either
“Refer:” It is recommended that the patient be referred to the level of
specialized burn service described
Or
“Discuss:” In such cases a discussion should take place with a Consultant
within the appropriate burn service and consideration given to referring /
transferring the patient to the appropriate service level.
• For Thresholds listed as “Refer”, it is acceptable (in exceptional
circumstances) for patients not to be transferred according to these criteria if
discussed with and agreed at Consultant level with the appropriate
specialized burn care service (i.e. the next service level up). Such agreement
should be recorded in the patient notes and all such cases should be
subjected to formal clinical audit.
• For the purpose of these guidelines a child is defined as being less
than 12 years of age.
• When the severity of burn injury is such that predictability of survival is
nil then end of life care will be instituted. For Adult patients, the
implementation of End of Life Care as a result of burn injury should only be
made following assessment by at least two Consultants using modified Baux
Score (one of whom should be a specialized Burn Care Surgeon).
Thresholds for the above criteria are listed as below: -

28
THRESHOLDS FOR REFERRAL TO ADULT BURN SERVICES
Criteria Facility Unit Threshold Centre Note
Threshold Threshol
d
TBSA Refer 3%<10% 10%<30% 30% The minimum
indication for Inhalation
(including 10%<20% with 20% Injury is defined as
those with inhalation injury with
– Visual evidence of
inhalation inhala- suspected upper airway
injury) tion smoke inhalation,
injury laryngoscopic and/or
bronchoscopic evidence of
tracheal or more distal
contamination/injury or
unconscious at scene with
suspicion of inhalation or
raised COHb.
If there are any concerns
regarding inhalation injury
with a patient with any size
burn then it should be
discussed with a Burn Care
Discuss 25% Special Consideration
should be given to referring
patients >65 yrs with 25%
TBSA (especially where
there are co-morbidities) to
the Burn Care Centre

Depth Refer Any full 5%<40% if All burns that are not
thickness non- blanching should be
referred to a specialised
burns blanching burn service
Site Refer Any burn to special Any “Significant” can mean any
areas (hands, feet, significant injuries where the referrer
burn to feels that greater MDT
face, perineum, expertise is required
genitalia) special area

Any non-blanching
circumferential
burn
Discus Any
s burn to
special

areas (hands,
feet, face,
perineum,
genitalia)
Mechanis Discuss Any
m chemical,
electrical,
friction burn.
Other Refer Any
Any cold
burn not Any predicted or actual
Factors healed in 2 need for HDU or ITU
weeks. level care

Any burn with suspicion


of non-accidental injury
should be referred to
a Burn Unit / Centre
for expert assessment
within 24 hours

29
Criteria Facility Unit Threshold Centre Note
Threshold Threshold

Other Discuss Any concern Patients who are All patients with The treatment of
Factors regarding burn pregnant Major Trauma + Burn patients with Major
injury and co- Injury (post treatment Trauma + Burn
All patients with within Injury
morbidities Major Trauma + Burn
including any Injury (post treatment Major Trauma Centre) should be agreed
within Major Trauma between the
co-morbidities where the burn injury
Trauma
that may affect Centre) where the meets centre level service and the
treatment or burn injury meets unit thresholds. appropriate
healing of the level thresholds. Patients assessed specialised
burn. as requiring end burn service (in
of life care should accordance with
be discussed with the
a Consultant Burn TBSA,Depth, Site
Specialist at a Burn and
Centre (to discuss the Mechanism criteria
appropriateness of listed above)
local palliative care
versus transfer to a
centre).

30
3.3(b) Clinical Protocols, SOPs and Standards of Clinical
Care

Specific Protocol for shifting of patient from Emergency


department, or other health care facility to Burn &
Reconstructive Surgery facility / unit / Centre:
ADMISSION AND TRANSFER POLICY
The emergency staff should initially assess the patient and inform
telephonically the burn facility/unit/ center team on call. In the meanwhile, the
first aid should be started. Definite treatment should be instituted after the
advice of burn facility/unit/ center team. The patient if needs admission
(according to the admission and referral guidelines of burn committee) will be
referred to burn facility/unit/ Centre through central referral services once the
bed availability has been confirmed accompanied by the referral form duly
filled.
NEW BURN PATIENTS (FIRST 48 HOURS OF BURN)
All such patients will be directly taken to the nearest surgical emergency. The
surgical emergency team will assess the patient. The initial assessment will
include: -
 Triage of patients as per ATLS protocol
 Clearance of another specific care/need e.g. for head/spine injury
clearance of neurosurgeon or for a fracture clearance from orthopedic
surgeon.

As per guidance for admission of burn patient, a request will be generated by


surgical emergency team and will also be informed telephonically, to the
nearest available burn service through central referral system.
OLD MAJOR BURNS (AFTER FIRST 48 HOURS)
All such patients will be directly taken to the nearest surgical emergency. The
surgical emergency team will assess the patient. The initial assessment will
include: -
 Triage of patients as per ATLS protocol
 Clearance of another specific care/need e.g. for head/spine injury
clearance of neurosurgeon or for a fracture clearance from orthopedic
surgeon.

As per guidance for admission of burn patient, a request will be generated by


surgical emergency team and will also be informed telephonically, to the
nearest available burn service through central referral system.

31
BED CAPACITY
The total admissions of the patients will not exceed at any time from the total
bed capacity of the burn service assigned burn beds. In case of disaster, the
disaster protocol should apply.

BURN DISASTER
They will be triaged in Emergency department of Hospital with on call team of
burn centre and will be shifted to burn centre on availability of beds; special
effort will be made to create space by discharging stable patients. Or shifting
them to surgical wards of the same hospital.
• Burn patients with wound infection at presentation
All such patients fulfilling the burn centre admission criteria with > 20 %
TBSA having positive cultures or element of sepsis will be managed in
quarantine/isolation room in Burns ward on availability of the bed.

• In case of isolated burn injury or burn disaster all the patients must be
transported to the Accident and emergency of Hospital adjacent to a
specialized burn service.
• They will be daily updated about the availability of the beds in burn
centers across Punjab by central bed bureau /central referral service.
INITIAL ASSESSMENT FOR A REFERRAL TO BURN UNIT;
Initial assessment of a burn patient includes same criteria as it is for other
trauma patients.
The detail assessment is done prior to referring a patient to a burn center as
shown below in the chart. This form duly filled should accompany the patients
during transfer to a burn facility.

32
SOP’s FOR ACUTE BURN MANAGEMENT AND REFERRAL CRITERIA
FROM EMERGENCY TO BURN CARE FACILITY/ BURN UNIT/ BURN
CENTRE
1. The Specialized Burn Care Network comprises of i) Burn Facility (8-bedded
ward in DHQ, 4-bedded ward in THQ), ii) Burn Unit (4-bedded HDU and 20-
bedded ward in all tertiary care hospitals) and iii) Burn Centre (with ICU,
HDU, blood bank, 24 hour theatres, skin bank facilities).

2. The A&E staff should perform the Primary Survey in Triage as per ATLS
protocol followed by Secondary Survey (neurosurgeon, orthopedic,
intensivist etc).

3. The A&E staff should inform telephonically the Burn Facility/ Unit/ Centre
team on call through central referral system.

4. Once initial resuscitation is completed, Burn Referral or Discussion will be


considered at consultant level depending upon TBSA, Depth, Site and
Mechanism of Burn.

5. Referral of a burn patient must follow the Ladder of level of injury


complexity starting from Burn Facility, followed by Burn Unit and then to Burn
Centre at its extreme level.

6. Referral must be through a Centralized Burn Referral Services after


confirmation of bed availability and it should have coordination with 1122
services in all districts.

7. The Referral Form should accompany the patients duly signed by DMS of
respective hospital A&E during transfer to a burn facility.

8. The Referral Services should keep up-to-date record of available beds in all
burn care services and there should be a Centralized Burn Registration.

9. End of Life Care Facility (when burn severity is such that predictability of
survival is nil) assessment by at least two consultants (one of whom must be
a Burn Care Surgeon). This facility must be present in every burn facility/ unit/
centre.

10. Total admissions to the burn care facility/ unit/ centre should not exceed at
any time from the total burn bed capacity (for acute burns) of the burn service.

11. In case of a Burn Disaster, all burn victims will be triaged in A&E department
of adjacent hospital and will be shifted to respective burn care system
depending on bed availability. If no beds are available, patients must be
shifted to surgical wards of the same hospital. Alternatively, a nearby burn
services team will respond at the disaster site, do triage and refer the patients
to respective burn care system as per level of burn injury.
12. All burn patients with >20% TBSA having positive cultures or signs of sepsis
must be managed in Isolation room in Burn wards.

33
13. For minor burns not requiring admission to a specialist burn care system:
i) Clean wound with 0.1% Chlorhexidine, normal saline or clean
tap water.
ii) Apply silver sulfadiazine or Vaseline guaze dressing.
iii) Make follow-up appointments with specialist unit in OPD.

14. All burn patients less than 12 years of age are defined as PAEDIATRICS and
must be treated by Paediatric Burn Care system or Paediatric Surgery
Department of a tertiary care hospital. These patients should not be
transferred to other tertiary care hospitals.

15. There must be a separate Specialized Burn Fund for management of Burn
patients required to purchase skin substitutes, dressings and other
disposables.

16. Special Burn Care Allowance should be added to the staff salaries.

17. All Burn Centres must work independently in terms of their administrative and
financial management but remain with the medical university.

34
APPENDIX 1: BURN PATIENT EMERGENCY ASSESSMENT & MANAGEMENT CHART
Place patient label here or:
Reg. No:
To be used for patients requiring transfer to a burn Name:
unit D.O.B: Sex:
Cnic: Ward:
Presentation Date: Time: Trauma Call: ◻ YES ◻ NO
Burn Date: Burn Time: Triage Category:
Weight ( Kg): Doctor:
Burn Mechanism:

Airway Breathing – O2

Intubation required Y/N RR Air Entry


size of tube O2 saturation
Cervical Spine Burn circumferential around chest / neck? ◻ Yes ◻ No

◻ Normal ◻ At Risk ◻ Immobilised


Circulation – 2 x IV lines

HR BP / Circumferential burns? Yes/No specify


Size and location cannulas
Cap refill centrally ◻ 1-2 seconds ◻ > 2 seconds ◻ Absent
Cap refill peripherally ◻ 1-2 seconds ◻ > 2 seconds ◻ Absent
Disability Environment Patient Temp. C @
Level of consciousness (AVPU):
AVPU = A – Alert, V - Response to Vocal stimuli, (time/date) Temp route
P - Responds to Painful stimuli, U – Unresponsive Remove clothing and jewellery
Pupils: (L) mm (R) mm Keep unburnt areas warm
Warm IV fluids ◻ No ◻ Yes ◻N/A
Warm blankets ◻ No ◻ Yes ◻ N/A
Assess % Total Body Surface Area (TBSA) burnt using Rule of Nines (see page 2)

Fluid Resuscitation (see page 3 for specific fluid calculations)


◻ Not required Large bore IVCs (2 for >20%, 1 for >10%) or CVL inserted ? ◻ Yes ◻ No
Bloods taken: ◻ FBC ◻ EUC ◻ BSL ◻ Coags ◻ COHb ◻ Drug screen IDC
Inserted? (if > 10% TBSA or perineum) ◻ Yes ◻ No
Nasogastric tube inserted? (if > 15% TBSA) ◻ Yes ◻ No
Co‐existing injuries? ◻ Yes ◻ Possible (e.g. blast / electrical injury) ◻ No
Specify
Pain Management Morphine (alt if allergic) Immunisation
Adults Stat IV 2mg, repeat every 5mins as required Immunisations up to date? ◻ No ◻ Yes
Max. 0.2mg/ Kg Specify
Children Stat IV 0.1mg/ Kg, repeat every 15mins as Tetanus status: ◻ Primary course given
required Max. 0.3mg/ Kg ◻ Last dose of booster
Minor burn Oral analgesia (e.g. paracetamol +/- ◻ Give Immunoglobulin if < 3 doses
codeine / oxycodone, etc.) may be adequate ◻ Give booster if last booster > 5yrs ago

35
Rule of Nines Palmar

Adult Palm + fingers = 1%

Paediatric

For every year of life after 12


months take 1% from the head
and add ½% to each leg, until
the age of 10 years when
adult proportions (Patient’s hand)

BURN DISTRIBUTION (shade affected areas on diagram below)

Shade affected
area

Total % TBSA

NB Faint
erythema not

36
RESUSCITATION FLUIDS
(>15% for adults)

Weight Kg
Modified Parkland Formula = 3‐4 mLs x weight ( Kg) x % TBSA burn
to be given as Hartmann’s solution in 24 hrs following the injury (see Transfer Guidelines)
3-4 mLs x Kg x % TBSA = total fluids for 1st 24 hrs
* NB This is a guide only ‐ Titrate fluids to urine output*
Total resuscitation fluids in 24 hrs mLs
Start time Finish time
st
50% Replacement in 1 8 hrs following injury mLs
Total Fluid given prior to admission mLs
st
Subtract Fluid already given = fluid to be given to complete 1 8hrs mLs
st
Hourly rate for replacement (within 1 8 hrs) mLs/hr
Start time Finish time
Remaining 50% of Replacement in next 16 hrs mLs

Hourly rate for replacement (in subsequent 16 hrs) mLs/hr


Start time Finish time
URINE OUTPUT
 Adults 0.5 – 1 mL/ Kg/hr
 2 mL/ Kg/hr required for pigmented urine such as myoglobinuria / haemoglobinuria

DRESSING
For transfer to specialist unit within 8 hrs apply cling film to burnt areas (Vaseline gauze/white paraffin for
face). Do not wrap circumferentially. For delayed transfer > 8 hrs apply antimicrobial dressing such as
Vaseline gauze or silver dressing, after discussion with burn unit
For burns not requiring transfer to specialist unit
 Give pre-med analgesia 30mins prior to procedure (e.g. paracetamol +/- codeine / oxycodone, etc.)
 Clean wound with chlorhexidine 0.1%, saline or clean water
 Apply appropriate dressing such as silver dressing or Vaseline gauze (see Minor Burn Management)
 make follow-up appointment and advise on care and analgesia for home usage and pre-dressing

37
HISTORY OF INJURY
When did it happen? Time: Date:
How did it happen?

Who saw it?

Who else was there?


What was done?
Was the burn cooled? ◻ No
◻ Yes If YES
when, with what and for how long?
MEDICAL HISTORY
Past Medical

History Co-

morbidities?
Allergies? ◻ No
◻ Yes If
YES specify?
Medications? ◻ No
◻ Yes If
YES specify?
Last oral intake?
Social History

SOCIAL ISSUES
Any features of concern? E.g. non-accidental injury/self-harm/abuse? ◻ ◻ Yes
No If YES specify?

Child Protection Service notified? ◻ No ◻ Yes Reference Number

Action taken
Signature:

Print name:

38
SECTION - 4:

REVIEW OF BURN CARE FACILITIES AT THE TERTIARY CARE


HOSPITALS
4.1 Overview
The committee identified tertiary care centres where there is either some existing
services of burn care or there is a potential for it in the form of a working plastic
and reconstructive surgery unit. Following is the list of the identified units.
1. Mayo Hospital Lahore
2. Services Hospital, Lahore
3. Shaikh Zayyed Hospital, Lahore
4. Lahore General Hospital, Lahore
5. Bahawalpur Victoria Hospital, Bahawalpur
6. Shaikh Zayyed Hospital, Rahim Yar Khan
7. Holy Family Hospital Rawalpindi
8. Khawaja Safdar Medical College, Sialkot
9. Nawaz Shareef Medical College Hospital, Gujrat

4.2 Details provided by respective tertiary care setups.

Mayo Hospital, Lahore


Currently Mayo Hospital has 51 bedded plastic surgery and burn ward. There are
4 bedded burn ICU, 8 bedded Burn HDU and 39 bedded Burn Reconstruction
Ward. The fourth floor of Surgical Tower is allocated for Burn and Plastic Surgery
Department comprising of 91 beds (Annexed-II).

Services Hospital, Lahore

Shaikh Zayyed Hospital, Lahore

Lahore General Hospital, Lahore


39
Information regarding burn management facilities: -

The Department of Plastic & Reconstructive Surgery is providing health care


facilities to Reconstructive Surgery Patients. At the moment there are no
allocated beds for acute burn patients. Current status of department is as under:
Sr. Number of Operating Equipment Personnel and
# Beds Facilities existing practices
of admitting burn
patients in your
department

1 20 Beds for Two operation General Plastic As the facilities are


Reconstructive theaters fully surgical not available for the
surgery patients equipped for Equipment management of acute
General Instruments set burn, so at the
Anesthesia Dermatomes moment acute burn
(For Skin Graft patients are not
Reconstructive Masher managed in the
Surgery Operative Department of Plastic
patients) Microscope and Reconstructive
Hand Held Surgery, Lahore
Doppler General Hospital,
Microsurgery Lahore.
Instruments

To improve the facilities for management of burn patients, PC-I for Burn Unit &
expansion of Department of Plastic & Reconstructive Surgery at Lahore General
Hospital, Lahore has been submitted through proper channel in March 2016, in
which demand of 20 beds for burn patients has been included with 5 beds for
HDU having ventilator, cardiac monitor and the necessary equipment for the
management of acute burn patients.

Bahawal Victoria Hospital, Bahawalpur


Currently there is a ten bedded Plastic surgery ward in BVH. The details of
current facilities and additional requirements to convert it into 40 bedded Plastic
Surgery and Burn unit are attached as (Annexed-III).

Holy Family Hospital Rawalpindi


At present there is an eighteen bedded burn unit with 10 beds for acute burns.
The details of existing facilities and requirements for immediate upgradation to 40
bedded Plastic Surgery and Burn unit are attached as (Annexed-IV).

40
Nawaz Shareef Medical College Hospital, Gujrat
At present there is 20 bedded burn unit with 10 beds reserved for acute burn and
10 for reconstructive surgery. The details of existing facilities and proposals for
upgradation are attached as (Annexed-V).

Shaikh Zayyad Hospital, Rahim Yar Khan


Burn and Reconstructive Surgery Unit consist of 26 regular in-patient beds, and
most of them are occupied by burn patients, however reconstructive and plastic
surgery patients are also accommodated in the same unit but general surgery
and orthopedic patients who need reconstructive surgery are admitted in their
respective units. In 2016 total 546 patients were admitted in burn unit, out of 546
patients 255 were acute (moderate to major) burns. In 2017, 493 patients have
been admitted till September; out of these 245 were acute burns.
Our burn unit is located at two sites in the hospital. Fourteen beds are in the old
building, 7 beds for each male and female bay. Presently these beds are mainly
used for reconstructive surgery patients. Twelve beds unit is located in the new
emergency building of the hospital and these are mainly used for acute burn
patients.
There is no Burn ICU facility for acute critical burn patients, even in the main 08
bedded ICU of over 900 bedded hospital, we never found a bed for such critical
patients who were in need of ICU care. The details of existing facilities and
proposals for upgradation are attached as (Annexed-VI)

Khawaja Safdar Medical College, Sialkot

4.3 Recommendations
The units at Mayo Hospital Lahore, BVH Bahawalpur and Holy Family Hospital
Rawalpindi will eventually develop into Burn Centres and details of their
upgradation/establishment are discussed in Section-5.
For the remaining units we propose that these units should be upgraded to 40
bedded Burn and Plastic surgery units where at least 20 beds should be
dedicated to care of acute burn patients. It is strongly recommended that there
should be a comprehensive upgradation including infrastructure, equipment and
human resource as per approved yard stick by SHC&ME.

41
SECTION - 5:

ESTABLISHMENT OF NEW BURN CENTRES

5.1 International Guidelines for Population Based Burn


Services Availability
There are no specific population based guidelines for establishment
of burn centres / units because the incidence of burn injury varies widely
amongst different countries of the world. Low Middle Income Countries (LMIC)
according to WHO report has much higher incidence compare to high income
countries (HIC) in USA. 25 to 46 % population lives within one to two hours by
ground transport of a varied burn service and there are altogether 51 accredited
burn services (Burn Centres / Burn Units) for a population of 323 million.
Overall the number of burn care beds is 65 beds per 10 million population.
Even at that proportion Province of the Punjab with population of
110 million should have 700 beds. However, our incidence of major burn injuries
is far greater than that of USA.

5.2 Recommendations
1. The Burn Unit at Mayo Hospital / KEMU is the oldest dedicated
burn facility in the province. Keeping in view the population
explosion in the metropolitan area of Lahore and its surroundings,
one Burn Centre i.e JB&RSC will not be able to cope with the
expected work load. In our proposed burn network, JB&RSC will
have additional responsibilities mentioned in Section – 2 (2.5) and
Section – 3 (3) Pivotal Role. More over there is a need to have a
burn centre to cater for vast catchment area from north west of
Lahore. In view of these facts and looking at the facilities that will
be available in Surgical tower, the committee strongly recommends
that Department of Plastic Surgery and Burn unit, Mayo Hospital
KEMU should be declared as Mayo Burn and Plastic Surgery
centre. This can be achieved in shorter period of time with relatively
smaller budget because of already available infrastructure and
procured equipment. In view of the available facilities the
committee proposes that the burn unit at mayo hospital be
upgraded to a burn centre status providing the additionally required
human resource as per approved yard stick and any additional
equipment needed. A PC I to that effect should be prepared and
vetted by this committee.

42
2. A regional burn Centre at Rawalpindi should be planned adjacent to
holy family hospital. PCI should be prepared by the project director
and should be vetted by this committee.
3. The PC I of proposed burn Centre at Bahawalpur Victoria hospital
Bahawalpur may be revisited by the same committee.
4. Pediatric burn centres may be established in Children Complex
Hospitals in Lahore, Multan, Faisalabad and Rawalpindi.
A committee of experts should be notified to prepare/review the
comprehensive plans of these 4 Children Burn Centers.

New Burn Units:


The committee proposes 40 bedded plastic surgery and burn units in following
tertiary care health facilities.
1. Sahiwal Medical College Hospital.
2. Gujranwala Medical College Hospital, Gujranwala.
3. DG Khan Medical College
4. Sargodha Medical College Hospital. Sargodha.

New Burn Facilities:

SECTION – 6:
43
TRAINING PROGRAM

6.1 Training of Doctors working in Burn Centres / Units in


core skills
6.2 Training of referring doctors
6.3 Training of Nurses and Paramedics and Rescue /
Ambulance staff
Training
Specialized training in the field of critical care, infection control, burn wound
management mainly for the burn centers and tertiary care burn units’ staff.
Training for non-core healthcare workers:
1. EMSB (emergency management of severe burns)

Emergency Management of Severe Burns (EMSB)


For training of the staff of emergency department and surgical
wards a course should be introduced that is an accredited course in
burn management recognized by HEC /CPSP. The College of
Physicians and Surgeons Pakistan (CPSP) can be asked for
proposals of Certifications in EMSB.

2. It should be a mandatory for all the doctors working in Emergency


and Accident department of any health care facility under health
department.

3. Specific Advice to Emergency Response Team (RESCUE 1122) for


immediate treatment and transfer of burn victims:
4. Refresher and short term residential courses in non-major burn
management.
5. Training of rescue paramedics in first aid and pre hospital burn
management and disaster management.

44
 For Both Adult and paediatric Burn Care
 Experience is required in respective age group.

Capacity Minimum Education and Minimum


Requirement Training Number
Consultant Burn Completed Accredited Continuous Facility:
Surgeon postgraduate professional Unit:
qualification in Plastic development by Centre:
Surgery Fellowship, workshop
Optional: Additional or courses
fellowship or
experience in Burns
Consultant Completed Accredited Continuous Facility:
Anaesthetist postgraduate professional Unit:
qualification in Plastic development by Centre:
Surgery Fellowship, workshop
Optional: Additional or courses
fellowship or
experience in Burns
Intensivist Completed Accredited Continuous Facility:
postgraduate professional Unit:
qualification in Plastic development by Centre:
Surgery Fellowship, workshop
Optional: Additional or courses
fellowship or
experience in Burns
Medical Officer/ M.B.B.S. or Equivalent Continuous Facility:
1 year experience in professional Unit:
Burns development by Centre:
EMSB/ABLS in burn Fellowship, workshop
care or courses
Post Graduate M.B.B.S. or Equivalent Continuous Facility:
trainee in Plastic 1 year experience in professional Unit:
Surgery/Burns Burns development by Centre:
EMSB/ABLS in burn Fellowship, workshop
care or courses
Nurse (Burn Basic Nursing Degree Continuous Facility:
ward/HDU) 1 year experience in professional Unit:
burns development by Centre:
Optional: Diploma or Fellowship, workshop
degree in burns or courses
EMSB/ABLS in burn
care

45
Capacity Minimum Education and Minimum
Requirement Training Number
Nurse (Critical Basic Nursing Degree Continuous Facility:
Care) 1 year experience in professional Unit:
burns critical Care development by Centre:
Optional: Diploma or Fellowship, workshop
degree in burns or courses
EMSB/ABLS in burn
care
Physiotherapist Basic Degree Continuous Facility:
1 year experience in professional Unit:
management of burn development by Centre:
patients Fellowship, workshop
or courses
Occupational 1 year experience in Continuous Facility:
Therapist burn care professional Unit:
development by Centre:
Fellowship, workshop
or courses
Clinical 1 year experience in Continuous Facility:
psychologist burn care professional Unit:
development by Centre:
Fellowship, workshop
or courses
Nutritionist Continuous Facility:
professional Unit:
development by Centre:
Fellowship, workshop
or courses
Social worker
NGOs

Recommendations:
For Doctors:
 1 to 2 year Fellowship in Burns with Induction from Plastic surgery with atleast 3
months rotation at world renowned Burn centre abroad.
 Provision of Emergency Management of Severe Burn (EMSB) or Acute Burn Life
Support (ABLA) courses for trainee doctors, Medical Officers and doctors
working in A&E.
 Annual burn care refresher course for doctors and consultants.

For Nurses and Paramedics:


 6 Months to 1 year Diploma or degree in Burn Care for Nurses.
 6 Months to 1 year Diploma or Degree in Burn Critical Care Nurses.

46
 6 Months to 1 year Diploma or Degree for Paramedics.
 Annual burn care refresher course for Nurses and Paramedics.

For Rescue 1122 / similar organizations


 Emergency Burn Care courses 6 monthly to yearly including first aid and safe
transport for severe burns.

For General Population


 Organization of burn prevention seminars
 Funding raising for rehabilitation of burn patients
 “Burn Survivor day”

A detailed calendar of training programme for each cadre of staff will be prepared
by this Committee upon approval by the competent authority.

47
SECTION – 7:
PREVENTION
7.1 Overview
In an attempt to confront the burden of burns, we want to suggest a
broad based strategic plan referred to as “The Burn Plan”. The purpose
of burn plan is development and implementation of the most effective
burn prevention strategies which have been successful from around
the world, and from a wide spectrum of economic situations. As with
any other health problem, burns can be addressed effectively and
scientifically. This includes: -
1. Identifying the risk factors for burns through surveillance
and research;
2. Developing well thought out prevention strategies that
target these risk factors;
3. Evaluating the results of these strategies rigorously, so
that once that work can be promoted and the once that do
not can be stopped, with resources shifted elsewhere.
Developing effective interventions is only part of the picture. There is a
need to implement them population-wide, which requires a public
health approach combining Engineering, Legislation, Enforcement, and
Education (3 Es) through engineering and social marketing. For all of
this, there is a need for advocacy, coalition building, and collaboration
between different sectors and groups who may not be used to working
together.
In an effort to identify major risk factors we did an informal studies at Jinnah Burn
& Reconstructive Surgery Centre, Lahore in the last 15 months, the most
common etiological factors of thermal injuries are: -
1. Gas Leakage (Domestic)

2. Cylinder Blast (Work Place)

3. High Voltage Electrical Injuries

4. Petrol Decanting

5. Acid Throwing

7.2 Strategies
Strategies should be developed by Public Health Experts to work
on these areas.

7.3 Recommendations

48
Prevention and rehabilitation programs for general population: -
 Organization of burn prevention seminars
 Fund raising for rehabilitation of burn patients
 “Burn Survivor Day”

Many burns are preventable, and any prevention campaign needs


to be targeted to appropriate groups, sustained and evaluated for its
success. To design the burn prevention / fire safety campaign, a study
paper developed by Hashmat Effendi – Burn and Plastic Surgery
Department Shalamar Hospital, Lahore is Annexed-VII.

49
SECTION – 8:
SUMMARY AND FINAL RECOMMENDATIONS

1. Referring to section 2.2 the shortcomings in infrastructure was highlighted


under sub heading Infrastructure. The committee proposes that respective head
of burn centers be asked to furnish a proposal to rectify these issues in shortest
possible time with minimum expenditure in such a way that proposed civil work
would not interfere with functioning of the unit.

2. Referring to section 2.3 the shortfalls in inventories of the equipment was


reviewed by the committee. The respective heads were asked to initiate a
demand of requisite equipment. The lists provided by all three centers are
discussed under sub section 2.3 above. The committee recommends that the
SH&MED should take prompt necessary action
3. Referring to Section 2.4: The additionally required human resource was
assessed by the committee after acquiring information from each burn centre.
The committee recommends that the respective heads of units may initiate SNE
for additional requirement of trained human resource immediately. It is also
recommended that the SHC&MED should facilitate approval of these
requirements on priority basis.
4. Special efforts have to be made to retain our trained staff and committee
suggests following measures to that effect;
(i) Improving the working environment: In house stress
management sessions will be arranged to combat that. Other
initiatives to tide them over include; workplace social events,
high standard cafeteria and recreational facilities.

(ii) Incentives: financial and other ‘in kind’ incentives would go a


long way in keeping the staff morale high. special burn care
allowance should be added to the staff salaries. (equivalent to
one basic pay or market based salaries), subsidized on site
accommodation for essential on call staff will be an attractive
bonus to retain the staff.

5. Referring to section 2.5, the committee unanimously recommends that all


the burn centres should be independent in terms of their administrative and
financial management but remain with the medical college / university as
affiliated hospitals.

50
6. The committee proposes a uniform referral guidance for these centers.
The competent authority should ensure compliance by the referring healthcare
institutions in order to prevent these centers deteriorating into kind of dumping
grounds for all kind of burn related injuries that will render them incapable of
performing their basic function of treating complex acute burn patients in isolation
with strict infection control providing modern critical care. The referral guidelines
established by the committee are discussed at pages 26 to 37.
7. Combined specialized burn care services network should be established
comprising of regional burn centers, all tertiary care health facilities treating adult
burns population.
8. Jinnah Burn and Reconstructive Surgery Center (JB&RSC) has a
proposed management structure in the PC-I envisaging it as Autonomous
Medical Institution (AMI) with its own Board of Management, academic autonomy
as Institute of Burn Care and Reconstructive Surgery and clinical linkages with
Allama Iqbal Medical College & Jinnah Hospital Lahore. A formal request to
declare JB&RSC, Lahore as AMI / AHI is under consideration by SHC&MED that
may be implemented.
9. The Units at Mayo Hospital Lahore, BVH Bahawalpur and Holy Family
Hospital Rawalpindi will eventually develop into Burn Centres and details of their
upgradation/establishment are discussed in Section-5.
The Burn Unit at Mayo Hospital / KEMU is the oldest dedicated burn facility in the
province. Keeping in view the population explosion in the metropolitan area of
Lahore and its surroundings, one burn centre i.e JB&RSC will not be able to cope
with the expected work load. In our proposed burn network, JB&RSC will have
additional responsibilities mentioned in Section – 2 (2.5) and Section – 3 (3)
Pivotal Role. More over there is a need to have a burn centre to cater for vast
catchment area from north west of Lahore. In view of these facts and looking at
the facilities that will be available in Surgical tower, the committee strongly
recommends that Department of Plastic Surgery and Burn unit, Mayo Hospital
KEMU should be declared as Mayo Burn and Plastic Surgery centre. This can be
achieved in shorter period of time with relatively smaller budget because of
already available infrastructure and procured equipment. In view of the available
facilities the committee proposes that the burn unit at Mayo Hospital be upgraded
to a Burn Centre status providing the additionally required human resource as
per approved yard stick and any additional equipment needed. A PC-I to that
effect should be prepared and vetted by this committee.
10. For the remaining burn units we propose that these units should be
upgraded to 40 bedded Burn and Plastic Surgery Units where at least 20 beds
should be dedicated to care of acute burn patients. It is strongly recommended
that there must be a comprehensive upgradation including infrastructure,
equipment and human resource as per approved yard stick by SHC&ME.

51
11. A regional Burn Centre at Rawalpindi should be planned adjacent to Holy
Family Hospital. PC-I should be prepared by the Project Director and should be
vetted by this committee.
12. The PC-I of proposed Burn Centre at Bahawalpur Victoria Hospital
Bahawalpur may be revisited by the same committee.
13. Pediatric Burn Centres may be established in Children Complex Hospitals
in Lahore, Multan, Faisalabad and Rawalpindi.
14. A committee of experts should be notified to prepare/review the
comprehensive plans of these 4 Children Burn Centers.
15. Training programs for Doctors, Nurses, Paramedics, and Rescue 1122 /
Similar Organizations discussed under Section – 6 are recommended to improve
the skill level of the workforce.
16. Prevention and rehabilitation programs for General Population: -
 Organization of burn prevention seminars
 Fund raising for rehabilitation of burn patients
 “Burn Survivor day”

52
REPORT OF THE COMMITTEE
CONSTITUTED

TO REVAMP BURN CARE SERVICES

IN PUNJAB

53
TABLE OF CONTENTS
1. Foreword 1
2. Terms & Glossaries 2
3. Section - 1: Introduction 3-5
4. Section - 2: Review of Services at Existing Burn Centres 6-22
2.1 Overview 6
2.2 Infrastructure 6-7
2.3 Equipment 8-10
2.4 Human Resource 11-19
2.5 Management 20-
21
2.6 Recommendations to improve services at the 22
existing burn centres
5. Section - 3: Review of referral practices and workload at existing burn 23-
centres 36
3.1 Prevalent referral practices 23
3.2 Workload 23
3.3 Recommendations: 23-
25
(a) Referral guidelines 24-
28
(b) Clinical Protocols, SOPs and Standards of 29-
Clinical Care 36
6. Section - 4: Review of burn care facilities at the tertiary care hospitals 37-
39
4.1 Overview 37
4.2 Details provided by respective tertiary care setups 37-
39
4.3 Recommendations 39
7. Section - 5: Establishment of New Burn Centres 40-
41
5.1 International guidelines for population based burn 40
services availability
5.2 Recommendations 40-
41
8. Section - 6: Training Program 42-
45
6.1 Training of Doctors working in Burn Centres / Units 42
in core skills
6.2 Training of Referring Doctors 43
6.3 Training of Nurses, Paramedics and Rescue / 43-
Ambulance Staff 44
6.4 Recommendations 44-

54
45
9. Section - 7: Prevention 46-
47
7.1 Overview 46
7.2 Strategies 46
7 3 Recommendations 46-
47
10. Section - 8: Summary and Final Recommendations 48-
50

ANNEXURES

S.# Description Page No.

1. Annexure – I: Approved Yardstick / Criteria for Creation of Staff 1-19

2. Annexure – II: Mayo Hospital, Lahore 20-24

3. Annexure – II: B.V. Hospital, Bahawalpur 25-32

4. Annexure – III: Holy Family Hospital, Rawalpindi 33-36

5. Annexure – IV: Nawaz Sharif Medical College, Aziz Bhatti 37-40


Shaheed Teaching Hospital, Gujrat

6. Annexure – V: Sheikh Zayed Medical College / Hospital, 41-55


Rahim-yar-Khan

7. Annexure – VI: Burn Prevention Program 56-60


Study Report – Hashmat Effendi

8. Annexure – VIII: Graphic view of New Burn Centres, Units, 61


Facilities

55
i

COMMITTEE MEMBERS

1. Prof. Dr. Moazzam Nazeer Tarar, Chairman


Professor of Plastic Surgery,
Executive Director, Jinnah Burn & Reconstructive
Surgery Centre, AIMC, Lahore

2. Additional Secretary (Technical), Convener


Specialized Healthcare and Medical Education
Department

3. Prof. Dr. Mughees Amin, Member


Professor of Plastic Surgery, B.V. Hospital,
Bahawalpur

4. Prof. Dr. Muhammad Saeed Cheema, Member


Professor of Plastic Surgery, Allied Burn Centre,
Faisalabad

5. Dr. Naheed Ahmad Chaudhry, Member


Associate Professor of Plastic Surgery, Burn Centre,
Nishtar Medical University, Multan

6. Any Member to be co-opted by the Committee Member

(i) Dr. Mustehsin Bashir, Co-Member


Associate Professor, King Edward Medical University,
Mayo Hospital, Lahore

56